Healthcare Provider Details

I. General information

NPI: 1730247636
Provider Name (Legal Business Name): DANIEL MICHAEL CALLISTO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BELLEFONTAINE AVE
LIMA OH
45804-2800
US

IV. Provider business mailing address

1001 BELLEFONTAINE AVE
LIMA OH
45804-2800
US

V. Phone/Fax

Practice location:
  • Phone: 419-998-4575
  • Fax: 419-998-4586
Mailing address:
  • Phone: 419-998-4575
  • Fax: 419-998-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number34004687
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: